<div class="title">{ %lang p1 }</div>
<form action=""  method="post">
<table cellpadding="4" cellspacing="4">
<tr><td>{ %lang p2 }</td> <td><input type="text" name="email" size="30" ></td>  </tr>
<tr><td>{ %lang p3 }</td> <td><img src="{ #imageurl }" border="0" ><br><input type="text" name="check" size="30" /> </td>  </tr>
<tr><td align="center" ><input style="font-weight:bold;" type="Submit" name="PasswordSubmit" value="{ %lang p4 }" > </td></tr>
</table>
</form>
